Fixed dilated pupilla as a common complication of deep anterior lamellar keratoplasty complicated with Descemet membrane perforation.

Purpose: To report 8 cases of fixed dilated pupilla (FDP) (Urrets-Zavalia syndrome) following deep anterior lamellar keratoplasty (DALK) with Descemet membrane (DM) perforation and change of management to avoid FDP.

Methods: Retrospective analysis of 106 eyes of 94 patients who underwent DALK for various diagnoses was performed. Intraoperative and postoperative details of eyes that developed DM detachment, FDP, as well as change of management to prevent rise of intraocular pressure (IOP) (as a common trait of these eyes) were evaluated.

Results: Descemet membrane perforation developed in 17 (16%) eyes. Fixed dilated pupilla was diagnosed in 8 (7.5%) eyes. Seven of the eyes with FDP experienced DM perforation and air bubble was left in anterior chamber (AC) to tamponade DM perforation at the end of the surgeries. Five eyes developed FDP in the early postoperative period and the remaining 2 eyes, which were diagnosed as double AC and managed by repeated air injections, developed FDP in the third postoperative week. The last patient who experienced intense postoperative inflammation had a fixed dilated pupil in the third postoperative week.

Conclusions: Fixed dilated pupilla is an uncommon but well-known complication of keratoplasty. The exact mechanism remains unknown but postoperative high IOP seems to be an important risk factor following complicated DALK. Rise in IOP during the management of complications following DALK related to DM was found to be important in the development of FDP in this series.